We read with great interest the paper by Chakravarty et al. (1) regarding percutaneous coronary intervention (PCI) of the left main coronary artery (LM) in patients after transcatheter aortic valve replacement (TAVR). In this TAVR-LM registry study, 9 patients were revascularized after TAVR. Difficulty in engaging the coronary ostia after TAVR has been well documented by Blumenstein et al. (2) in one of the largest case cohorts of 35 patients (10 patients with CoreValve). They also have suggested specific catheter recommendations (2). Greenburg et al. (3) also discussed in 2 case cohorts the challenge of engaging the coronary ostia after CoreValve implantation, with a preference for left over right radial catheterization to minimize negotiation within the aortic stent and the valve leaflets (3).

At our institute, we encountered a challenging case of multivessel PCI in a patient with a CoreValve from the right radial approach. Our patient was an 87-year-old woman with multiple comorbidities, post-TAVR with a Medtronic CoreValve (29-mm prosthesis), who presented with unstable angina. During coronary angiography, catheter manipulation was difficult because the catheter tip became trapped in the stent struts and there was resistance from the CoreValve frame. Despite the use of multiple diagnostic/guide catheters, only a nonselective angiogram of the left coronary artery was able to be performed with an Amplatz left-1 catheter, and PCI of the mid left anterior descending coronary artery was performed with a 6-F internal mammary guide positioned outside the left main nonselectively. The right coronary artery was selectively engaged with an Amplatz right-1, and PCI of the mid right coronary artery was performed with a Judkins right 3.5 catheter.

Being prepared for possible challenges with catheter engagement in patients post-TAVR (especially with the CoreValve) is valuable. We would like the corresponding author to share the PCI experience in the post-TAVR group (n = 9), the access approach, and the challenges associated with the procedure.

Footnotes

Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose. John Bittl, MD, served as Guest Editor for this paper.

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